Shadows over the "Golden Decade": how certain HIV-infected populations have not benefitted fully from the scale-up of anti-retroviral therapy and what can be done about it

The global fight against HIV/AIDS saw considerable improvements during the past decade: Anti-retroviral therapy (ART) and HIV diagnostics became cheaper and better, treatment initiation criteria were broadened, and better funding mechanisms were established. Access to ART improved substantially in Sub-Saharan Africa (SSA) and life expectancy of HIVinfected patients increased.This period has been coined as the “Golden Decade” of ART. However, this overall success story does not apply to all HIV infected people in SSA equally. Certain sub-groups of HIV-infected people in SSA have not benefitted from the scale-up of ART to the same extend. In particular, these are HIV-infected people in rural areas,pregnant mothers,and children and adolescents. The main problem in rural areas is physical access to care due to poor transport infrastructure and technical requirements for diagnostic devices. For HIV-positive pregnant mothers, the main challenge is retention in care during the most critical neo-natal phase. For children and adolescents, late diagnosis and treatment initiation leads to avoidable mortality. At the same time, the increased number of patients on ART hasput health systems in SSA under enormous stress, and current models for decentralization of caredo not keep up with the scale of the problem. Several interventions have proven efficacious under clinical trial conditions for all of these patient groups. Such findings have guided the development of international treatment guidelines, which have become increasingly ambitious by broadening treatment access and lowering initiation criteria. This led to a discrepancy between prescriptive standards of care and programmatic realities in the actual implementation of care. Operational research, defined as research on interventions and strategies to improve programmes in which the research is carried out, is a valuable yet under-utilized method to identify shortfalls in the delivery of care, and to assess the effectiveness of interventions for these neglected subgroups of HIV-infected people